The impact of utilization management on readmissions among patients with cardiovascular disease

Objective. To determine if prospective utilization reviews that lead to red uced hospital length of stay (LOS) relative to days requested by an attendi ng physician affect the likelihood of readmission for privately insured pat ients with cardiovascular disease. Data Sources. Data obtained from a private insurance company on utilization management decisions from 1989 through 1993. During this five-year period, 39,117 inpatient reviews were conducted, 4,326 (11.1 percent) on patients with cardiovascular disease. We selected for analysis all 4,326 reviews per formed on patients with cardiovascular disease. Study Design. We used proportional hazard analysis (Cox regression) to inve stigate the relationship between LOS reductions relative to days requested by a patient's attending physician and the likelihood of readmission within 60 days of discharge. Separate analyses were performed for medical and pro cedural admissions. Principal Findings. There were 2,813 requests for medical admission, and 1, 513 requests for procedural admission. Requests for admission were rarely d enied. Length of stay was reduced relative to that requested by the treatin g physician for 17 percent and 19 percent of medical and procedural admissi ons, respectively. Cumulative 60-day readmission rates were 9.5 percent for medical admissions and 12.3 percent for procedural admissions. We found no relationship between LOS reduction and the likelihood of readmission for m edical admissions. However, patients admitted for procedures who had their length of stay reduced by two or more days were 2.6 times as likely to be r eadmitted within 60 days as those who had no reduction in their length of s tay (95% CI: 1.3-5.1; p < .005). Conclusions. Utilization management (UM) rarely denies requests for inpatie nt treatment of cardiovascular disease. The association between LOS reducti on and the likelihood of readmission for patients admitted for cardiovascul ar procedures raises concern that UM may adversely affect clinical outcome for some patients. Further research is needed to definitively elucidate any relationship that might exist between utilization review decisions and qua lity of care.